Ways to talk about Diabetes Meds Tom Ransom Div. Endocrinology, Capital Health April 5, 2018

Transcription

1 Ways to talk about Diabetes Meds Tom Ransom Div. Endocrinology, Capital Health April 5, 2018

2 Disclosures Faculty/Presenter: Tom Ransom Relationships with commercial interests: Grants/research support: Research trials: Principal/Sub Investigator, CDHA, Endocrinology Research, Centre for Clinical Research. Speaker s bureau/honoraria: Consulting fees: Speaking honoraria: Sanofi, Astra Zenica, BMS, Merck, Sepracor, Pfizer, Servier, Lilly, Abbott, GSK, Novartis, Novo Nordisk. Advisory Boards: Merk & Co., Boehringer Ingelheim, AstraZeneca, Novo Nordisk. Other:

3 Outline Old standards Insulins Metformin, S.U. s, acarbose, orlistat Newer meds Incretins SGLT2 s

4 Some of my favorite lines that I ve adopted Think like a pancreas Start low and go slow (when appropriate) I m not trying to guess what you need. I m deliberately giving you less than you need so you can titrate up safely. I want you to be comfortable making adjustments. We are better at checking and reacting than predicting Start on a weekend

5 1 vs. 2 Different diseases that happen to overlap with hyperglycemia End stage DM2 can be similar to DM1 from a glycemic point of view DM2 more complex but more strategies

6 Type 2 Diabetes is progressive 6

7 MDI Basal I hate the liver! Unrelenting glucose production glucose machine Daily rhythm that s fairly constent It s not a scam. Sugars are higher in the morning The basal handles the liver

8 MDI Bolus You need more insulin for a bowel of Cheerios at breakfast than at supper l more less My pancreas squirts out more insulin for pasta with garlic bread than for a Caesar salad with chicken strips

9 It sits in your skin Not This This It s the formulation that effects how long it lasts and how fast it acts

10 Metformin My Favorite Drug Helps the body be more sensitive to insulin Reduces how much glucose the liver puts out Safe, safe, safe (but avoid in advanced kidney disease does not harm the kidneys)

11 Secretagogues OK in not aiming for super tight control Be careful in the elderly Long and short acting just like insulin

12 Acarbose Used in the Stop NIDDM trial Delays absorption of the absorption of sugars from starches but blocking the enzyme in saliva that breaks starches down Less of a peak after you eat But the starches reach the colon Try keeping a piece of bread in your mouth for 2 minutes it becomes sweet

13 Blocks fat absorption Orlistat Start low and go slow Start on a weekend

14 Incretins What we told you before was a big lie The hormone GLP1 is responsible for about 2/3 of insulin release do to a meal As soon as you start eating the breaks start coming on

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17 Incretins Most people experience nausea when they start If it starts of annoying it will go away, if it starts off horrific it might only improve to miserable There is no equation to say this drug = 20 units of insulin so you will need to reduce insulin especially if A1c is under 8% Start on the weekend DPP4i s safe for the heart, GLP1 s benefit GLP1 s = DPP4i s plus but are expensive

18 SGLT2 s

19 SGLT2 s Diabetes translated into English literally means pee a lot Melitis french for honey We can take advantage of this and allow even more sugar to pass so instead of the sugars going up they go out Blood sugars come down and calories get flushed down the toilet

20 BUT Anyone with DM is at risk for yeast infections because of sugar in the urine more sugar means more risk Polyurea may be an issue Risk of dehydration in the elderly There is no equation to say this drug = 20 units of insulin so you will need to reduce insulin especially if A1c is under 8% Start on the weekend **so far one has been shown to be cardioprotective

21 Conclusions I do not have any evidence but I strongly believe that an informed patient is more likely to take the medication that they choose Please share you pearls